Flashcards in Spoken Language Disorders Deck (71):
What are the three major language and speech disorders?
2: Speech Apraxia
What other disorders are associated with language impairment?
Dementia and confusional states
What is Aphasia?
Disorders of language processing usually resulting from focal brain pathology/infarctions/lesions.
What is Apraxia?
A general term for motor disorders in which motor planning abilities are damaged.
Speech Apraxia is inability to correctly plan and execute necessary muscle movements required to produce speech
What is Dysarthria?
Neurological pathology of sensorimotor connectivity/pathways of muscles characterized in difficulty to utilize the affected muscles.
What are the two major types of clinical observation when assessing aphasia?
1: Large deficits in linguistic and communicative performance in conversation
2: Linguistic proficiency across modalities and different types of language tasks
What are the different tasks used to assess different processes of language?
Repetition, oral and written naming, writing to dictation, reading aloud, speech and script comprehension.
What are the different aphasic symptons?
Speech Automatism: compulsive repetition of words
Agrammatism: reduction of grammatical elements
Echolalia: Repetition of partner.
Phonemic, jargon, neologistic: Use of unintended phonemes
Paraphasia:unintended use of word/phoneme in speech (phonetic/semantic)
Perseveration: Use of old response in new context
Stereotypy: repetitive use of phrases instead of pauses.
Word finding: great difficulty in finding words
To types of aphasic speakers?
Non-fluent: Great effort for little speech production
Fluent: Fluent speech riddled with errors
Speech automatism is a symptom which?
Almost exclusively occurs in aphasic patients
What are the errors to look out for when performng naming tasks?
Delayed naming: slowed activation/selection of lexical target
Self-correction: recogntion of error
Circumlotion: failure to retreve lexical target.
Near Semantic Paraphasia: wrong but meaning-related word
Unrelated word: failure to access target
Visually related word: failure in visual object analysis
perseveration: Failure to inhibit previous response
Gesture: Compensatory gestures
What are the advantages of naming tasks compared to speech tasks?
Fewer degrees of freedom. Typically there is only one correct response. The lexical target is known and lexical analysis becomes easier.
Reveals specific domains of deficits. (Visual naming (optic aphasia), word access, etc.).
Task can be too easy for some aphasia patients.
What causes optic aphasia?
Disconnection of connectivity between visual association cortex and language regions.
Unable to retrieve words corresponding to visual stimuli but can retrieve the same words when asked verbal questions (What do you open a lock with?)
What is a nonword?
Phoneme sequence that does not constitute a meaningful word.
What is the purpose of repetition tasks?
To identify which route there is damaged. Lexical or semantic routes show different symptoms. If there is damage to lexical processes. Patients will be unable to repeat nonwords.
What does the term "syndrome" denote?
A statistical cluster of co-occurring symptoms
What does analysis of clusters reveal?
70-80% of patients are grouped together with symptoms relating to acute and chronic aphasia.
They also reveal that here are differences in symptoms caused by ischemic or non-ischemic damage.
Three groups of classification systems are used:
Modality oriented: Distinguishes on the basis of assumed dissociation across modalities
Anatomically oriented: Distinguishes on the basis of location of damage. (anterior/posterior aphasia etc.)
Linguistic deficit: Fluent/non-fluent distinction based upon ease, speed, length of speech production
What are the differences between acute and chronic aphasia?
Time post onset.
Different kinds of pathophysiology.
Penumbra and diaschisis enlarges function lesion in acute cases. Chronic cases there is a cerebral reorganisation which reduces deficit
Acute cases are associated with other additional disorders of conciousness, attention, and awareness.
What is diaschisis?
When damage to one area causes damage to another not adjacent area because of lost connectivity
What is important to note about the relationship between acute and chronic aphasia?
Acute cases of aphasia and shown symptoms can not be directly compared to well-known chronic aphasias. Usually it develops post lesion/infarct into one of the syndromes of chornic aphasia.
Aphasia resulting from lesions to thalamic areas results in what rare symptoms?
Acute Phonemic paraphasia, Perseveration, and fluctuating attention/conciousness.
What are the 8 syndromes of aphasia?
What is special about global aphasia?
Global denotes that all language processes are severely damaged. It is non-fluent. it is stereotyped if speech production even happens.
Speech automatism supersedes intended production. Writing modality might be superior.
What is special about Broca's Aphasia
Functional interpretation is closer to Apraxia.
Non-fluent. Repetition intact. Principle feature is reduced linguistic proficienci on phonological (simplified phonemic structure), lexical (word finding), and syntactic (agrammatism) levels. Agrammatic symptoms are quite specific to Broca's aphasia.
What is special about Wernicke's Aphasia?
Characterized by "para-symptomatology" (co-occurring symptoms). Phonemic/semantic paraphasia, Neologism/jargon, paragrammatism. Fluent speech production with little error correction. Language comprehension typically more damaged than in Broca's
Develops towards more anomic or unspecific residual aphasia with time.
Damage to Wernicke's area commonly caused by posterior cerebral infarction.
What is special about Anomic Aphasia?
Inability to lexical access and/or retrieval. Fluent speech and comprehension. Massive efforts to find intended words which results in: Pauses, circumlocutions, semantic paraphasia, evasion of target word with fillers (thingy, thing, etc.) and empty phrases, or discontinuation of sentence in favor of a variation of the statement.
Usually results from lesions in posterior border regions of core language areas.
What is special about Conduction aphasia
Disconnect between sensory and motor areas of language, which results in a failure to monitor output and control. Wernicke predicted this! Fluent speech.
Distinguish between two types of conduction aphasia:
1st: Prominent repetition of phonological short-term memory.
2nd: impairment of phonological out put programming for single words which together with preserved monitoring results in a lot of correction and repetition (pure conduction aphasia). Good prognosis if encountered with acute aphasia
What is special about the transcortical aphasias? (motor, sensory, mixed).
Preserved ability to repeat and comprehend is preserved.
connection between sensory and motor speech areas are intact.
Greatly reduced production.
Associated with lesions in left frontal lope outside of Broca's area, especially in the vicinity of supplementary motor area (SMA) and left basal ganglia. Related to initiation of speech.
Sensory and mixed are rare and usually observed in dementia patients. Characterized by disinhibited echolalia.
What are the core objectives of the diagnostic instruments of aphasia?
Establishing severity of condition
Analyzing the neuropsychological or neurolinguistic structire of deficits as a basis for treatment and evaluation of test batteries.
Analysing the effect of aphasia on ability to communicate.
What are the different test batteries for Aphasia?
The token test: Simple assessment of severity
Boston Diagnostic Aphasia Examination: Most frequently used battery
Aachen Aphasia Test: Limited test with the advantage of supporting single-case statistics psychometrically.
Frenchay Aphasia Screening Test: A brief clinical test designed for nonspecialist use.
Psycholinguistic Assessment of Linguistic Processing in Aphasia (PALPA): Assesses a wide variety of language processes intended for mapping the deficits of a single patient.
The Amsterdam-Nijmegen Everyday Language Test: A test designed for more ecological situations.
What more can you say about BDAE? (Boston Diagnostic Aphasia Examination)
Most frequently used battery that includes 27 subtests which assess spoken and written language aswell as associated functions.
It provides norms from a collective of aphasics as Z-scores. Assigns syndrome on basis of test results.
What characterizes speech apraxia?
It describes pathology which affects patients ability to articulate desired speech. Symptoms include: Distortions, substitutions, and dysprody.
Apraxia denotes a deficit on the level of motorprogramming and execution.
Apraxia can be related to different areas and must be seperated from these. Speech apraxia affects speech and is not neccesarily related to oral apraxia.
What are the symptoms of speech apraxia?
Phonetically characterized by inconsistent errors related to phonemic target. Errors include: omission, substitution, distortion, addition, and errors of sequence. These errors are affected by word complexity
Parapraxia often occurs in speech apraxic patients. WHat is it?
Errors on the level of movement elements when speaking. Without technical investigations it can only be observed with anterior articulators and inferred via phonetic signal by an experienced examiner.
What are the diagnostic instruments for speech apraxia?
There currently no generally accepted clinical instruments for assessment of speech apraxia.
What is dysarthria?
Disorders of sensorimotor performance of speech acts which is characterized by disturbances in speech musculature control due to paresis, slowness, incoordinationk aotered tone or additional (dyskinetic) movements.
What is notable about the causes of dysarthria?
Sensorimotor speed and quality of movements can be caused or affected by a variety of disorders: Lesions of first and second motor neuron, ataxia, akinesia, dys/hyperkinesia, sensory impairment.
Neurological diseases result in mixed forms of dysarthria. Neurodegenerative disease, MS, ALS, Motorneuron degeneration.
Dysarthria are classified into 5 different categories:
What diagnostic instruments are used?
Frenchay Dysarthria Assessment: Consists of a standardized investigation of speech and nonspeech motor acts, respiration, phonation, comprehensability, spontaneous speech.
What's the biggest difference when observing Apraxia or Dysarthria?
Apraxia is cortical where as Dysarthria is muscular. They can be seperated by determining muscular function.
What are the different groups of articulators to keep in mind?
Lungs, Chest wall, diaphragm: Respiration, controlling breath.
Balance vocal cords: Respiration, control of loudness, stress patterns, intonation
Larynx: Voice control, pitch and loudness.
Lips: Hyper/hypotonus. Unable to control lips.
Mandible: Affects tongue and lip control
Other disorders can have the same symptoms as Apraxia while stille maintaining normal rate of speech and intonation. Which symptoms are these?
Phonological, paraphasic, premotoric disruption to output planning.
Which symptons follows a lesion in the dominant temporal parietal, insular, and/or frontal cortex?
Impaired planning, supervision, execution of movements of speech: Results in phonological disturbances and apraxia of speech.
Which symptoms follows damage to the right temporal-parietal, frontal cortex?
Control of aspects of intonation.
What symptoms are displayed after a lesion to upper motor neuron in the pyramidal pathways?
Transmission of impulses from M1 via cortical bulbar and spinal tract to lower motor neurons is damaged.
Basal ganglia lesions are associated with which symptoms?
Initiation, scaling, maintenance, alternation and smooth concatenation of movements.
Cerebellum damage leads to deficits in?
Feedforward control, coordination, and integration of movements. Also the cognitive affective components of speech.
What does lower motor neurons do?
Transmit nerve impulses from upper neuron to muscles.
Synaptic junction does what?
Does the same as lower motor neurons
What is the best way to assess these motor disorders?
There is debate as to how most effectively assess these. It involves different verbal/nonverbal tasks to identify muscular deficits in relevant muscle groups and also if they are isolated to production of language, or if they are more general motor deficits.
What are other motor disorders that might affect a patients ability to speak?
Dystonias: Neurogenic movement disorder characterized by involuntary muscle cramps.
What are the different types of dystonia?
Focal dystonia: Localized to one area or muscle group.
Action dystonia: Cramps that spontaneously arise during one specific activity. May spread to other activities.
What other disturbance can affect speech?
Tics (as seen in Tourette syndrome and OCD)
Palilalia: Being stuck on a particular sound
Tremors like parkinson's disease can affect speech production.
What weird quirk is related to neurogenic malfunction?
Development of a foreign or old accent. Acquired foreign accent syndrome.
What are the three core principles when treating spoken language disorders?
1: Aim to directly recover lost skills or functions by promoting degrees of neural reorganisation through repeated and structured practice.
2: Additionally compensate for communicative strategies by developing strategies drawing on retained skills
3: Develop strategies which shape a more ideal environment for the patients recovery and communication.
What is important to note when treating dysarthria?
The nature of dysarthria and prognosis varies wildly depending on the nature of the cause.
Vascular aetiology or a lesion may expect good recovery, while patients with progressive conditions will never recover.
There are four goals of therapy:
1: To restore or improve muscular function for those who can expect physiological recovery
2: To maintain neuromuscular function for as long as possible, e.g. in cases of progressive disorders
3: To compensate for lost function, especially if recovery is not possible
4: To provide psychological support.
What steps in the assessment proces are critical to planning effective therapy?
Probing individual's view about their problem. Ideally, therapy is client-driven.
Identifying a target for intervention.
Knowing the nature of the patient's symptoms.
Identifying a suiting approach to the particular patient
Identifying patient resilience factors
Identifying environmental factors in cooperation with patient and significant others.
Providing a baseline from which to measure progress
There are three primary therapy approaches:
Speech-oriented behavioural approaches
Compensatory behavioural approaches
What are the speech-oriented behavioural approach?
Exercises and drills that directly aim to improve neuromuscular function and restore speech.
Primary goal to restore lost function.
Exercises that directly aim to improve respiration, phonation, or articulation during speech
What are compensatory behavioural approaches
Does not aim to directly improve neuromuscular function but instead develop strategies that compensate for lost function.
Exercises that compensate by modifying pauses during speech for example.
What are the communication-oriented approaches?
An approach that compensates via changes to the environment. Adaptive strategies for patient and listener in order to better communicate.
What does a typical therapy cycle involve?
Discussion and explanation of the rationale of the exercise and its relation to the problem
Practice with hierarchically structured tasks
Feedback and self-evaluation
Repeated practice - progressive difficulty
Practice in conversational tasks.
Instruments can be used in therapy to provide a baseline and measure progression in deficit areas.
Which kind of instruments are used?
U tube manometer: Air pressure during exhalation
Kinematic instrumentation: Records chest wall movement.
Visipitch, visispeech, speech viewer: Visual feedback of vocal parameters such as frequency, duration, intensity etc.
Nasometer: Nasal and oral accoustic energy/resonance
EMG feedback: Feedback of muscle activity
When treating Apraxia there is no loss in ability to utilize muscles. Treatment here is split in two categories:
Speech planning therapy: Which aim to restore lost function and improve on planning. Exercises of progressive difficulty. Needs to be chosen depending on severity of condition.
Communication-oriented therapy: Similar to compensatory approach in dysarthria patients. Aims to Compensate through strategies that aid communication
What are the 5 different programmes of direct treatment?
8 Step Continuum: A hierarchy of stimuilus presentation from imitation to quiestion/answer response
Melodic Intonation Therapy (MIT (lol)): Uses preserved singing skills to elicit speech via intoned utterances.
Prompts for restructuring Oral Muscular Targets: Physical prompts on relevant areas to train planning.
Minimal Pairs Treatment: Organized practice of minimal pair contrasts. (Sheet vs seat, etc.)
Intersystemic Facilitation/Reorganization: Uses relatively intact systems to aid improvement in impaired system.
Where should goal setting start in Aphasia therapy?
Start with the person:
What kind of communications are they attempting/failing at?
What would they like to improve?
What are their main skills?
What is the purpose of goal setting?
Providing a baseline from which to compare progress.
Provides a meaningful direction of treatment for the patient.
Aids greatly in identifying and evaluating compensatory strategies and difficulties for the patient's engagement in different environments.
There are direct and indirecty therapy approaches that are specifically aimed at different symptoms of aphasia. Can you guess the different aspects of aphasia these therapies treat?
Word comprehension: Word sound discrimination therapy; Written/spoken word matching/discrimination tasks; Improving semantic processing.
Production problems: Word finding therapy; Phonological therapy; Relay Therapy;
Connected speech and conversation: Event therapy; Mapping Therapy; Verb Access Therapy; Syntax Training; treatment of underlying forms.